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00030010 CITY OF CUPERTINOPERMIT NO. BUILDING DIVISION PERMIT C©N RACTOg R IINFOO +MATION'c• 00030010 BUILDING ADDF4'".S: e,/ /yrn03 001��. SPB SANITARY NO. APPLE?),) Ica/ 00�DATE O alE '5N• lint //// / /VN/iV'MA^ ///V•-. 3/ J C/ NIC CONTROLp �ysys�72 ° ARCHITECTIENGINEER - - BSI DI OPERM'1 NIiO n'o o S /0 U F i LICENSED CONTRACTOR'S DECLARATION Job Description Z O y_ I hrm ereby drithat i am licensed under pmvuneas of Chapter 9 tcommern n p C� u9 wiNSation 7000)Df Division 3 of Ne Business end nProfession$Code,and to i t s /}/. uy in full force and ellen. ,�r/�i�17 L;y� ��� �jt� n �O /�/'i�/J//I a/ e� //(J,eate� Oyj Li...0 B n// Wc.M' Mp/ l`/ (//r� V�1 > 3 LL y Dete —Conwctsr f-u.O a ARCHITECTS DECLARATION rcI understand my plans shall be used u public eceds ne¢ne E d a o LicensedRn(nasio.l KJ^_y OWNER-BUR-DER DECLARATION " !-Z< 1 hereby affirm that 1 am exempt from Ne Consommes License law for the `$t�m following reason.(Section 7031S.Business and Professions Cade:Any city or county d dF which oquims a Permit m construct,alter,improve,demolish,or repent any structure Sq. Ft. Floor Area V/;;�11I uatI D Prior to its ismance,elan"nine lbe applicant for such permit m rile a signal statement V o Oidt he is licensed puouam no the pmvisio.of dte Contracmes License law(Chapter 9 - (commencingwith SecOon7ODO)of Division3oflhe Buainessand NofessionsCWe)or NAPN Number �,�at he is exempt thucfrom and the basis For the alleged exemption.Any vialmon of - ecu Pane Ty •J Pe Section 7D31.5 by any applicant for a Formal subjrcu the applicant to a civil pe.lty of 1 more On Bve hundred dollars(S500). p I,asmwernrthepmpeny.nrmyemploycnwithw.gnnstlre'umlemnmpeoudw, 13 Required Inspections willdothewerk,end the structure is netanted or offered fee We(Sm.7014,Business and Potation.Code:The Contractor's License raw does not apply to an wren$of , ,.Perry who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements me,not intended or oRered for Wee.If,how.,the building or improvement is within one year of completion,the owner-builder will have the burden of proving Out he did not build or improve for pur- - poseofsele.). Jj - ❑I,as owner of the property,an exclusively contracting with licensed contractors m cw$wd the projeet(See.7814,Business and Professions Code:)The Contractors Li- / cense Lew don rot apply je an owner of ptoputy who builds or impmvn thereon,end who contracts for such pmjecu with s contramortsl licensed punuant to Ole Contractsen ^.1 uo rte naw. I l✓V Aun exempt under Sm. ,BkPCfor this won Owner Dau WORKER'S COMPENSATION DECLARATION f hereby affirm undo podty of perjury one of the following declxwio.: - ❑I havesnd will Zituina Ceniflcauofeo.entre self-imen,forwnrkeracompen- v1. u provided for by Section 3700 of the Labor Code,for the performance of the wn�or which this permit is issued I have end will maintain Wmkaes Compensation insurance.es imputed by Section 3700 of the labor Cgapdeu,for the pcsfonwtce of tha work fm which this permit u intend. MYWar, ajlQgn//////!l yrvuecarrinxdd obey 11giDIApg�0�0/�� - Cerin: GC�//ffJJ �O /' Polio No.:11YArt" CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be cmmpietM ifthe permit it future hundred dollen($100) or lc..) I codify Nn in the performance of the work for which this pent is issued,l shall .in employ any room to any manner so as to become xubj.t ire the Worked'Comped- sation Laws of California.Data Applicxm . _NOTICE TO APPLICANT:IL after nutting this Caddies.of Exemption,you should . become subject to the Wnrknra Compensation provisions of the Labor Code,you must foMwelt comply with such provisions Or this permit that be coma d mrokm. , 0 Q _ CONSTRUCTION LENDING AGENCY I hereby affirm than them in censtmNmn lending agency for the performance of Z On work for which this permit is issued(Sec.3097,Ci,C.) 9 2 Lenders Name } Lender's Add.. W1 unify that 1 have read this application and awe that the above information is M. 0 correct I agree in comply with ell city and county m diene.and sun,laws relating m Z building construction,and hereby aithoden representatives oflhiscity to enter upon the V G above-mentioned property for inspection purposes. W F., We)agrtc m eve,indemnify and keep harmless the City of Cupertino against fJ lie hilao..judgments,costs end upen.which may in any way accrue against said City } W in co.equeme of grunting of Our penal, - lti APPLICANTUNI R.STANDS 'H WILL COMPLY WI"ffI AtI.NON-POINT C, g(1lIRCE RP.GIII �'ON' � � m r Signamm of Appppiiitnctin A, g ARDOUS MATERIALS DISCLOSURE W+Il the applicant or Powrt building nccupmt Imre or hendlehuudom meterid Re-roofs in definedby the Cupertino Municipal Code.Chapter 9.12,nd the Health and Safcty Code.Sec0om V5532(a)7 / Type of Roof ❑Yes 0 Will the applicant or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being annit heradoasair contaminants asdeBnedm by 'installed. If a roof is Installed without first obtaining an inspection District �Yet Vn - I agree to remove all new materials for inspection. Applicant I love mad the houndous mxudals expoinema moder Chapter6.95 of the Cali- Understands and will c mply with all non point source re ulatioris. Boom Health&5 ny Code,Sufioys 25505,25333 end 25534.1 understand that if Ota -� Inildingdarnd emly levo flim,datitumyrespo.ibilitymndirylhe outs t oft rryuirt ;Inchri et.t piorousuenceofe Certill cu n Signature of Ap Date If I Ow.rneuthorz Date All roof coverings to be Class`B"or better OFFICE